Immune and infectious

I.

II.

WBC
a. Neutrophils- increase in relation to acute bacterial infection and
fungal infection
b. Lymphocytes (T and B cells)- increased in relation to chronic bacterial
or viral infection, viruses such as mononucleosis, mumps, and
measles, bacteria such as hepatitis, lymphocytic leukemia, multiple
myeloma
c. Monocytes- increased in relation to chronic inflammation, protozoal
infections, TB, viral infections like mononucleosis, mumps, and
measles
d. Eosinophils- increase in relation to allergic reaction, parasitic
infection, chronic inflammation, Hodgkins disease
e. Basophils- increase with leukemia
Skin test for allergens
a. Involves the use of intradermal injections or scratching the superficial
layer of the skin with small amounts of suspected allergnes
b. Intradermal runs a higher risk of hypersensitivity reactions and is
usually done if the scratch test is inconclusive
c. Pre
i. Prepare the skin for application of various allergens using soap
and water (clients back or forearm are usually used for
testing)
ii. Alcohol may be used to remove oil
iii. Have equip ready for possible anaphylaxis reaction
iv. Instruct the client to avoid taking cortocsteroids and
antihistamines 5 days before the testing
d. Intra
i. Skin is scratched or pricked with a needle after application of a
drop of an allergen
ii. An assessment of reactions is done after 15-20 minutes
e. Post
i. Assess the skin for areas of reaction, and document the
allergen that is responsible
ii. Remove all solutions from the skin
iii. Inform the client when results will be available
iv. Recommend an antihistamine or topical corticosteroid if the
client experiences itching seco
v. ndary to the testing
vi. Keep for 30 mins after

III.

HIV/AIDs
a. HIV:
i. Manifestations occur within 2-4 weeks of infection
ii. Symptoms are similar to those of influenza and can include a
rash and a sore throat
iii. Rapid rise in HIV viral load, decrease CD4+ cells, and increased
CD8 cells
iv. Lymphadenopathy persists throughout the disease process
v. Chronic asymptomatic infection
1. This stage may be prolonged and clinically silent
2. Client may remain asymptomatic for 10 years or more
3. Anti-HIV antibodies are produced (HIV positive)
4. Over time, the virus begins active replication using the
hosts genetic machinery:
a. CD4+ cells are destroyed
b. The viral load increases
c. Dramatic loss of immunity begins
b. AIDs
i. Lie-threatening opportunistic infections
ii. End stage of HIV infection
iii. Without txt, death occurs within 5 years
iv. All people with AIDS have HIV, but not all people with HIV have
AIDS
c. Standard precautions
d. s/s:
i. chills, rash, anorexia, nausea, weight loss, weakness, fatigue,
HA, sore throat, night sweats
e. Stages
i. Stage 1
1. No defining conditions
2. CD4+ 500 or more
ii. Stage 2
1. No defining conditions
2. CD4+ 200-499
iii. Stage 3
1. One or more of the following:
a. Candidiasis
b. Herpes simplex- chronic ulcers
c. HIV related encephalopathy
d. Disseminated or extrapulmonary histoplasmosis
e. Kaposis sarcoma
f. Burkitts lymphoma
g. Mycobacterium TB of any site
h. Pneumocytisis jirovecii pneumona
i. Recurrent pneumonia

j. Progressive multifocal leukoencephalopathy

k. Recurrent salmonella septicemia
l. Wasting syndrome attributed to HIV
2. CD4+ less than 200
f. Other labs:
i. CBC and differential- anemia, thrombocytopenia, leukopenia
ii. Decreased platelet count less than 150,000
g. Medications
i. Highly active antiretroviral therapy (HAART)
1. Using three or four HIV meds in combo with other
antiretroviral meds to reduce medication resistance,
adverse effects, and dosages
2. Enfuvirtide, maraviroc, zidovudine, delavirdine,
atazanavir, saquivir, interleukin
ii. Antiviral meds increase ALT, AST, bilirubin, mean corpuscular
volume, HDLs, and total cholesterol and triglycerides
iii. Do not miss does, take on regular schedule
h. Client education
i. Practice good hygiene and frequent hand hygiene to reduce
risk of infection
ii. Avoid crowded areas and traveling to poor countries
iii. Avoid raw foods
iv. Avoid cleaning pet litter boxes
v. Keep home environment clean
i. Complications
i. Opportunistic infections
1. Implement and maintain antiretroviral meds as
prescribed
2. Admin antineoplastics, antibiotics, analgesics,
antifungals, and antidiarrheals as prescribed
3. Admin appetite stimulants to enhance nutrition
4. Monitor for skin breakdown
5. Maintain fluid intake
6. Maintain nutrition
7. Teach client to report signs of infection immediately to
the HCP
ii. Wasting syndrome
1. Maintain nutrition orally or by TPN if indicated
2. Provide between meal supplements/snacks
3. Serve at least 6 small feedings with high protein value
iii. Fluid/electrolyte imbalance
1. Monitor fluid and electrolyte status
2. Report abnormal lab data promptly
3. Maintain IV fluid replacement
4. Make dietary adjustments to reduce diarrhea

IV.

iv. Seizures (HIV encephalopathy)

1. Maintain client safety
2. Implement seizure precautions
Systemic Lupus Erthematosus
a. Autoimmune, atypical immune response results in chronic
inflammation and destruction of healthy tissue
b. Antibodies attack healthy tissue- may be triggered by toxins, meds,
bacteria, viruses
c. No cure
d. Increases with age
e. Discoid lupus- affects skin, erythematous butterfly rash ove rhte nose
and cheeks and is generally self-limiting
f. Systemic lupus- affects connective tissues of multiple organ systems
and can lead to major organ failure
g. May be difficult to diagnose because of the vague nature of early
manifestations
h. s/s
i. fatigue/malaise, alopecia, blurred vision, pleuritic pain,
anorexia/weight loss, depression, joint pain, swelling,
tenderness
ii. fever (major symptom of exacerbation)
iii. anemia, lymphadenopathy
iv. pericarditis (presence of cardiac friction rub or pleural friction
rub)
v. raynauds phenomenon (arteriolar vasopasms in response to
cold/stress)
vi. findings consistent with organ involvement (kidney, heart,
lungs, and vasculature)
vii. butterfly rash on face
i. Labs
i. Positive antinuclear antibody
ii. Positive anti-DNA
iii. Positive Anti-smith, anti-RO, anti-LA, anti-RNP, antiphospholipids
iv. Decreased serum complement (C3, C4)
v. Increased BUN/creat with kidney involvement
vi. Urinalysis- positive for protein and RBCs with kidney
involvement
vii. Pancytopenia
j. Nursing
i. Pain, mobility and fatigue
ii. VS- especially BP
iii. Small frequent meals
iv. Limit salt intake for fluid retention secondary to steroid
therapy
v. Emotional support

V.

k. Medications
i. NSAIDs
ii. Corticosteroids
iii. Immunosuppressants
iv. Antimalaraial- hydroxycholoroquine- encourage frequent eye
exams
l. Client education
i. Avoid UV and sun exposure- use sunscreen when outside and
exposed to sunlight
ii. Use mild protein shampoo and avoid harsh hair txts
iii. Use steroid creams for skin rash
iv. Report peripheral and periorbital edema promptly
v. Report s/s of infection
vi. Avoid crowds and those who are sick
vii. Educate client of childbearing age regarding risks of pregnancy
with lupus and txt medications
m. Complications
i. Lupus nephritis (renal failure/glomerulonephritis)
1. Monitor for periorbital and lower extremity swelling
and HTN
2. Monitor renal status
3. Teach importance of taking immunosupressants and
corticosteroids as prescribed
4. Avoid stress and illness
ii. Pericarditis and myocarditis
1. Report chest pain
2. Monitor for chest pain, fatigue, arrhythmias, and fever
3. Teach importance of taking immunosupressants and
corticosteroids as prescribed
4. Avoid stress and illness
Rheumatoid arthritis
a. s/s
i. pain at rest and with movement
ii. morning stiffness
iii. pleuritic pain (pain upon inspiration)
iv. xerostomia (dry mouth)
v. anorexia/wt loss, fatigue, paresthesias
vi. recent illness/stressor
vii. joint pain
viii. lack of function
ix. joint swelling/warmth/erythema
x. finger, hands, wrists, knees, and foot joints are generally
affected
xi. finger joints affected are the proximal interphalangeal and
metacarpophalangeal joints
xii. joints may become deformed merely by completing ADLs

xiii. ulnar deviation, swan neck, and boutonniere deformities are

common
xiv. subcutaneous nodules
xv. fever (low grade)
xvi. muscle weakness/atrophy
xvii. reddened sclera and/or abnormal shape of pupils
xviii. lymph node enlargement
b. labs
i. anti-CCP antibodies positive test
ii. RF antibody
iii. Elevated ESR- indicates inflammation
iv. positive c-reactive protein- monitoring response to antiinflam
therapy
v. positive antinuclear antibody (ANA)
vi. elevated WBCs
c. interventions
i. apply heat or cold to affected areas
ii. assist with and encourage physical activity to maintain joint
mobility
iii. monitor client for indications of fatigue
iv. teach to max functional activity, min. pain, monitor skin
closely, conserve energy, coping strategies, encourage routine
health screenings
v. safe environment
vi. progressive muscle relaxation
vii. report fever, infection, pain upon inspiration, pain in the
substernal area of the chest
viii. encourage foods high in vitamins, protein, and iron
ix. small, frequent meals
d. complications
i. Sjogrens syndrome
1. Triad- dry eyes, dry mouth, dry vagina
2. Provide eye drops and artificial tears and recommend
vaginal lumbricants
3. Fluids with meals
ii. Secondary osteoporosis
1. Immobilization caused by arthritis can contribute to the
development of osteoporosis
2. Encourage weight-bearing exercises as tolerated
iii. Vasculitis (organ ischemia)
1. Inflammation of arteries can disrupt blood flow, causing
ischemia
2. Smaller arteritis in the skin, eyes and brain are most
commonly affected in RA
3. Monitor for skin lesions, decrease in vision, and
symptoms of cognitive dysfunction

VI.

VII.

Kaposis sarcoma
a. With AIDS
b. Can be found on the ahrd palate, gums, tongue, or tonsils
c. Lesions appear as raised, purple nodules or plaques
Infection
a. Best way to prevent health-care associated infection is for frequent
and effective hand hygiene
b. Standard precautions
i. Applies to all body fluids, non-intact skin, mucous membranes
ii. Hand hygiene before and after gloves and between patients
iii. Clean gloves
iv. Masks, eye protection, face shield if there is a risk of splash
v. Private room is not needed
c. Airborne
i. Measles, varicella, pulmonary, or laryngeal TB
ii. Private room
iii. N95 or high-efficiency particulate air respirator mask
iv. Negative pressure airflow room
d. Droplet
i. Strep pharyngitis or pneumonia, scarlet fever, rubella,
pertussis, mumps, mycoplasma pneumonia, meningococcal
pneumonia/sepsis, pneumonic plague
ii. Private room or room with same infectious disease
iii. Mask for providers and visitors
e. Contact
i. RSV, shingella, enteric disease, wound infections, herpes
simplex, scabies, MRSA, C. diff, impetigo
ii. Private room or room with same infection
iii. Gloves and gowns by caregiver and visitors
iv. Disposal of infectious dressing material into a single,
nonporous bag without touching the outside of the bag
f.